“Eight hours work, eight hours recreation, eight hours sleep"—this timeless slogan represents the aspiration for work-life balance. But not in the life of Accredited Social Health Activists (ASHAs) in India. Spending numerous hours working in challenging conditions, these health activists are the pillars of India’s health care system. Despite their important role, they are under-remunerated, overburdened, and underappreciated in the formal labour market. Recent state-wide strikes in Kerala, Karnataka, Bihar, and Maharashtra only serve to emphasise their demands for improved wages, secure employment, and social benefits.
Evolution of the ASHA program
The ASHA program was launched in 2005 under the control of the National Rural Health Mission (NRHM), with a vision to empower every Indian village with a trained woman health activist. The prime agenda was linking rural groups with the health system in the country and ensuring accessible health care at the grassroots level. The function of the ASHAs is a crucial liaison between their local population and the health infrastructure in the country and to get them access to health care and health awareness. By the year 2013, realising the need to expand health issues in the urban population, the program was extended under the National Health Mission (NHM) to reach the urban population under the National Urban Health Mission (NUHM). It was to take the success in rural ASHAs and scale them in the urban population to address the particular health problems in the urban poor population.
The process of selection is usually based on some criteria. Age is mostly in the range of 25-45 years, education is preferably a minimum of a 10th-grade pass and a permanent resident in the concerned village or area in the town. Once selected, the ASHAs are trained in comprehensive modules on a wide range of health issues such as maternal and child health, prevention and health promotion. They are guided and supervised by Auxiliary Nurse Midwives and health officers in the field, with ongoing support and monitoring.
Policy milestones
The ASHA program has seen major policy shifts over the years. In 2006, initial guidelines were issued, followed by performance-based incentives in 2010 and urban expansion under NUHM in 2013. By 2018, WHO recognised ASHA's contributions to reducing maternal and infant mortality, and in 2020-21, their crucial role in the COVID-19 response was acknowledged.
In May 2022, India's Accredited Social Health Activists (ASHAs) received the World Health Organization's (WHO) Global Health Leaders’ Award. This honour recognised their crucial role in linking communities with the health system, ensuring access to primary healthcare services, especially in rural areas.
Low wages and financial insecurity
Marx’s labour theory of value posits that workers should be compensated in accordance with the value they generate. ASHAs, who play a crucial role in public health, merit fair compensation that reflects their essential contributions. However, they often lack the necessary economic and institutional support to perform their duties effectively, despite their significant impact on public health. ASHAs frequently exceed their official working hours, addressing emergencies at all times. They manage various responsibilities, such as conducting home visits for maternal and newborn care, assisting with child immunisation initiatives, and raising awareness about non-communicable diseases like diabetes and hypertension. They also serve as first responders during health crises, including epidemics and pandemics like COVID-19, as well as providing palliative care and support. This demanding workload, which can extend to 12-14 hours daily, results in extreme fatigue and challenges in achieving a work-life balance.
Despite their indispensable role, ASHAs are compensated solely through performance-based incentives rather than receiving a regular monthly salary. Most of them experience payment delays and often find themselves in a position where they must take out loans or depend on their partner's income. The economic insecurity adds to their stress and predisposes them to depression. (ASHAs) are the primary intermediaries that connect the population and the health system.
Workload and lack of work-life balance
ASHA workers are crucial to India's healthcare delivery, particularly in rural areas. As first-contact healthcare providers, ASHAs often find themselves in emotionally challenging situations. They have to handle cases of maternal death or labour complications and sometimes face verbal and physical abuse while promoting vaccines and hygiene. These repeated exposures contribute to burnout, post-traumatic stress disorder (PTSD), and emotional exhaustion.
During the pandemic, Kerala's ASHAs conducted contact tracing, home visits for quarantined patients, and vaccination drives. Many reported experiencing insomnia, anxiety, and emotional breakdowns due to their overwhelming workload. In Uttar Pradesh, ASHAs were repeatedly targeted with aggression from local communities, particularly while administering polio immunisations. Physical attacks and threats, fueled by misinformation, placed them in constant danger, leading to high rates of trauma and stress-related disorders.
A study in Maharashtra found that 68% of ASHAs had fallen into debt due to delayed honorariums and meagre incentive payments. Most reported symptoms of depression and anxiety, struggling to manage their families' financial burdens.
Feminist Labour Theory critiques the systematic undervaluation of care work, which disproportionately affects women. ASHAs’ unpaid domestic labour, coupled with their professional duties, exemplifies double exploitation within patriarchal and capitalist frameworks. The inequality in pay has led to profound dissatisfaction among the ASHA workers. The majority of ASHA workers lament about not receiving appropriate remuneration in proportion to the volume and seriousness of their work. ASHAs are not entitled to health benefits, pensions, and other social security benefits like other government health workers. There are innumerable reports regarding the delay in the payment of honorarium and incentives, leading to financial strain. As a backlash, ASHA workers in various states have gone on strike and protest, seeking better wages, on-time payments, and improved working conditions. An example is the ongoing strike in Kerala, showcasing how imperative it is to address these issues.
The responsibilities of ASHA workers are notably more arduous than in the past, which may vary according to the state. For example in Kerala, in addition to their standard duties outlined by NHM guidelines, ASHA workers are also tasked with responsibilities at the Primary Health Center, alongside their regular obligations at health sub-centres, which generally operate on a 10-to-5 schedule. This necessitates travel to the Primary Health Center, which may be located at a considerable distance from their assigned sub-centers. Unfortunately, a significant number of ASHA workers do not have access to adequate transportation, resulting in substantial travel challenges and financial pressures stemming from transportation expenses.
Comparing ASHA’s to minimum wage standards
The Minimum Wages Act of 1948 empowers the Union and state governments with the authority to prescribe minimum wage scales in varying sectors. These are periodically revised to account for inflation and cost-of-living adjustments. The Union government revised wages with effect from October 1, 2024, applicable to construction, mining, and agricultural labour, among other sectors. The daily wages are prescribed at ₹783 for unskilled labour, ₹868 for semi-skilled labour, and ₹1,035 for highly skilled labour. Based on a working month of 26 days, these equate to monthly wages of around ₹20,358 for unskilled workers,₹22,568 for semi-skilled workers and ₹26,910 for Highly Skilled Workers.
Whereas southern states provide improved financial support, ASHA workers in northern states continue to face extreme wage disparities, being paid meagre honorariums that do not reflect their workload and contribution. ASHA worker wages vary extremely across India due to differing state government policies and budgetary allocations. Their earnings come primarily from three sources: a fixed monthly honorarium from state governments, state-specific incentives for additional tasks, and central government incentives under the National Health Mission (NHM).
Southern states like Kerala, Karnataka, Andhra Pradesh, and Telangana pay ASHAs a higher honorarium compared to most northern states. Andhra Pradesh, Karnataka, and Sikkim now offer one of the highest honorariums for ASHA workers at ₹10,000 per month—nearly seven times higher than Uttar Pradesh’s ₹1,500. Karnataka and Kerala supplement wages with additional fixed state incentives, which significantly boost total earnings but are much lower than the minimum wage. In contrast, Uttar Pradesh, Bihar, and Madhya Pradesh have extremely low fixed honorariums, rendering ASHAs dependent on irregular performance-based incentives. In India, an ASHA worker receives less than an unskilled labourer despite being entrusted with essential healthcare activities. The Union government’s minimum wage for unskilled industrial and agricultural workers (₹20,358 per month) far exceeds ASHA pay in most states, including those in the south, where honorariums remain below the prescribed minimum wage levels. Even in the best-paying northern states, ASHA workers earn less than ₹6,000 a month, far below the government’s suggested daily wage for unskilled workers (₹783/day).
One of the main reasons for this disparity is that southern states have historically spent more on social welfare and health. Kerala, Tamil Nadu, and Karnataka have higher health budgets per capita, which allows them to pay ASHAs better wages. Additionally, ASHAs in southern states are more literate and politically conscious, allowing them to organise protests and demand higher wages. ASHAs in northern states, particularly in rural Uttar Pradesh and Bihar, lack the same level of political influence. While geographical inequities exist, ASHA workers across India continue to face low wages, delayed payments, and a lack of social security. To address these imbalances, the government must institute national-level wage reforms, including universalising ASHA honorariums across all states with a minimum guaranteed honorarium of ₹21,000 a month, indexed to inflation, and prompt and regular payment of honorariums and incentives. It is time for the Union and state governments to act decisively, bringing in uniform wage reforms that guarantee financial security, dignity, and recognition for India’s ASHA workforce.
An international comparison
Brazil’s community health agents (CHAs) are institutionally hired and integrated within the country’s health system (SUS), with fixed wages, benefits, and social security, giving them greater job and motivational security. In contrast, ASHAs are volunteers and are mostly paid in the form of incentives, and their financial security is weaker. Likewise, the Lady Health Worker (LHW) program in Pakistan is based on a systematic model where LHWs are paid wages and performance-related incentives, and court struggles over a period have ensured their establishment as a category of government employees with greater job protection. However, there are no fixed wages in the case of ASHAs and their income is based on achieving a particular service-related performance indicator, and there is financial insecurity. The Health Extension Workers (HEWs) in Ethiopia are completely salaried employees with a systematic career structure and professional training and are working within the state’s health infrastructure with greater integration with state policies. There is no such systematic structure in the case of ASHAs with no definite position and no state backing, and there is insecurity in their financial and societal protection.
The call for changes in policy and legal recognition
There is a need to recognise ASHAs as Group C employees of the Union government and accord them benefits and labour rights. Also, the government should provide social benefits in the form of pensions, maternity benefits, and health insurance. Definite career pathways should be established to upgrade them in the future in such health roles as health supervisors or ANMs. Furthermore, training and capacity building programs should be strengthened to provide the ASHAs with newer medical knowledge and improve the quality of their service. The government must take initiatives to improve working conditions with enhanced access to transportation, medical supplies, and technology to lighten administrative loads.
The need for reform without delay
ASHAs are not only health workers but the backbone of India’s health care system. Providing Group C employee status for them with benefits such as a fair wage, social protection while ensuring professional progress is not only a matter of ethics but a significant investment. Formal inclusion in the list of government employees would improve their lives and enhance the efficiency and quality of health efforts in India.
Global models in Brazil, Pakistan, and Ethiopia show how organisational compensation and integration with the state are connected with better health. India has a lesson to learn here and ensure that ASHAs are given the dignity, respect and financial protection they deserve. As the need grows for labour rights, the movement for recognition of ASHA workers is gaining momentum. The hour is here to move beyond token appreciation and move on to realistic legislative intervention to ensure their future.
The author is a policy analyst and columnist